How to Choose the Right Health Insurance — and a Good Doctor

Every year, whether it be as an individual or as an employer, we must make a decision about health insurance — and along with that choice comes picking the group of doctors and hospitals that will deliver most of our care.

 

For some, this process is purely about affordability. But for others, it is also about coverage and providers. If you are among those with real options, there are certain considerations that should help guide your decision.

Let's start with where will you be able to be hospitalized for elective procedures. Although most people know at which hospitals they want to be cared for, not everyone is so lucky.

Growing up in Paramus, N.J., my parents taught me from a young age that if something ever happened to me, I should ask the ambulance driver to take me to Hospital A in the area and not B.

As a kid, I only knew what I heard;

as an adult handling malpractice cases, I learned why that was sound advice. For those looking for a method of deciding where they want their insurance to participate and their doctor to have admitting privileges, there are several rating agencies that you can look to for some guidance.

One place you can start is on the Centers for Medicare and Medicaid Services website. CMS provides a standardized survey and data collection system that results in public reporting known as the HCAPHS Star Rating system. This is one of several available means of comparing hospitals.

Another is the Joint Commission (previously the Joint Commission on the Accreditation of Hospitals or JACOH), which not only accredits hospital, it also provides certification in certain specialties.

Some ratings systems and rankings rate by department. In this instance, if you are a woman of child bearing, you will want to look more at the ratings of the Obstetrical Department. And if you are a man over 60, with high blood pressure and high cholesterol, it’ll be the ratings of the cardiovascular surgery program.

Additionally, two of the respected commercial ratings services are Healthgrades and Hospital Safety Score.

Healthgrades "designates hospitals with five stars (better than expected), three stars (as expected), or one star (worse than expected) based on their performance in specific conditions and procedures.”

The Hospital Safety Score uses "national performance measures from the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS), and the American Hospital Association's Annual Survey and Health Information Technology Supplement.

Taken together, those performance measures produce a single score representing a hospital's overall performance in keeping patients safe from preventable harm and medical errors.

The Hospital Safety Score includes 28 measures, all currently in use by national measurement and reporting programs. The Hospital Safety Score methodology has been peer reviewed and published in the Journal of Patient Safety.”.

Once you know where you would prefer to be admitted, the next step is identifying a primary care physician in the plan who can admit you to that hospital, if needed — not only because of where they can admit you, but because they are likely to recommend a specialist who can also admit to that hospital.

Now comes the tricky part: Picking a good doctor!

The first part is the easiest. They need to be board certified. If they are going to be your primary care physician, this generally means in internal medicine or family practice (although for your children this would mean pediatrics and for your parents, perhaps geriatrics).

Most people have heard of board certification, but what does it really mean? While the criteria are decided by the certifying board, they are similar for each specialty.

It generally includes completing a multi-year residency program in that specialty, then submitting an application to be found eligible to sit for that board's exam.

Someone who is eligible, but has not completed the full process is known as Board Eligible. Once found eligible to sit, one must pass a written exam. For many specialties, the person must then pass an oral exam and in some they must practice for a couple years before taking that oral exam.

Upon completing the requisite requirements, a doctor is then board certified. In the last 20 to 30 years, the boards have added mandatory recertification every 10 years. So, with the exception of some older physicians, keeping one's certification forces one to stay up to date.

Now it gets a little more involved for those who want to add a higher hurdle to their selection of a physician.

In most states the disciplinary boards provide online information about every registered physician. For example, by visiting www.njdoctorlist.com, the New Jersey Department of Consumer Affairs provides information about education, training, office locations, hospital privileges, board certifications, disciplinary actions and malpractice claims histories.

Of course, these require one to interpret the information for themselves. Publications like “Best Doctors in America” or “Top Docs” (as published in monthly magazines) provide generally reliable information on who are the doctors with the best reputations amongst their peers.

The one caveat to these are that in order to gain a reputation, one needs to practice for a long time, often resulting in a bias toward older doctors and leaving out some of the most recent highly-trained physicians.

Once you are interested in seeing someone, see if they have ever published anything regarding your medical condition. While this may be limited to situations involving non-emergent surgery, someone who has published on a subject has taken a special interest in that disease process or procedure, and their work has been deemed by colleagues to be useful to others.

When my daughter was young, she needed surgery for something called a cholesteatoma. I had never heard of this type of mass and when the potential surgeon mentioned facial nerve monitoring, I asked how many of these surgeries he had done.

He candidly offered that he had done "more than most and less than others." He then said, "If you search long enough you'll find someone who collects these in a jar."

And that was what we did. When we walked into the doctor's office, he had pamphlets about this thing I had never heard of before, and in his examining room was a notebook of articles he had written, about half of which were about cholesteatomas.

Lastly, there is no replacement for confidence in your physician and a sense that they are listening to you and answering your questions. Once you pick a doctor, make an appointment for a "new patient visit" (kind of a first annual physical).

You'll know when it is over if you've made the right choice — and that's what matters, that it is the right choice for you!

E. Drew Britcher, Esq. is the senior partner of Britcher Leone, LLC, a New Jersey Medical Malpractice and Personal Injury law firm. He is a Certified Civil Trial Attorney with more than 30 years’ experience representing plaintiffs in medical malpractice cases. He is a past president of the New Jersey Association for Justice (NJAJ), Chair of the NJAJ Medical Malpractice Section, counsel on dozens of reported medical malpractice court opinions, and was integrally involved in the drafting of New Jersey's Patient Safety Act.